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Sworn Disclosure

Have you ever been convicted of a law violation(s) but exclude offenses committed before your 18th birthday, which were finally adjudicated in a juvenile court under the youth offender law?

YesNo

If yes, please explain

Are you subject to any pending criminal charges?

YesNo

Have you applied to Fast Track Health Care Education before?

YesNo

When (if YES)

I certify that the information I have provided are true and complete to the best of my knowledge and understand that all information provided will be used by FAST TRACK to determine my qualification for admission. I understand that any false, misleading or incomplete answer statement or implication made by me in connection with this application or the application process, or any failure to disclose any relevant information, shall result in the denial and /or revocation of admission to FAST TRACK including dismissal from FAST TRACK if matriculated and may also lead to future denial and or revocation of licensure as a Practical Nurse, Nursing Assistant or Medication Aide. I hereby give FAST TRACK permission to investigate my personal, Criminal, educational and employment background and history and to contact persons, organizations, institutions or government agencies who may have knowledge of me. In Consideration for FAST TRACK reviewing my application for admission, and intending to be legally bound, I hereby release FAST TRACK subsidiaries, affiliates, trustees, officers, employees and agents (collectively hereinafter referred to as FAST TRACK), from any and all claims or liability, known or unknown, arising from FAST TRACK investigating my background and all persons, organizations, institutions or government agencies supplies such information. Finally, it is my understanding that I shall not be considered for admission to FAST TRACK until I have submitted all credentials and otherwise satisfied all requirements for a timely and complete application for admission. I further understand that an application which satisfies all application requirements is not guaranteed admission into FAST TRACK Nursing Program. I agree to inform FAST TRACK of any changes in the information I have provided on this application otherwise in connection with application process. If FAST TRACK offers me admission, and I decide to matriculate, I agree to comply with any and all of FAST TRACK policies, rules and regulations, as amended from time to time FAST TRACK does not discriminate on the basis of age, race, religion, gender, sexual orientation, national origin, disability or veteran status in its program and activities.